Hamzeh M. Halawani

Laparoscopic antral resection with Billroth I reconstruction for a gastric glomus tumor

Highlights • A 33-year-old woman presented with intermittent dull upper abdominal pain for two days. Abdominal computed tomography (CT) was performed showing a hyperdense mass in the antrum. Endoscopy and endoscopic ultrasound revealed a submucosal antral mass along the greater curvature, suspicious for a gastrointestinal (GI) stromal tumor (GIST), a laparoscopic antrectomy with Billroth I reconstruction was done.• Pathological examination revealed that the mass was a gastric glomus tumor. Gastric glomus tumors are fairly uncommon and mostly benign, with an estimated incidence of 1% of all GI soft tissue tumors.• This case may aid in improving the recognition and diagnosis of this rare entity and in differentiating it from more common GISTs and gastric carcinoids.• A built up knowledge between physicians is extremely necessary to avoid common confusion in taking the right medical approach.

Conversion of failed Roux-en-Y gastric bypass to biliopancreatic diversion with duodenal switch: outcomes of 9 case series

INTRODUCTION Weight regain after Roux-en-Y gastric bypass (RYGB) is a frustrating long-term complication in some patients. Revision of RYGB to biliopancreatic diversion with duodenal switch (BPD-DS) is an appealing option. There is a paucity of information in literature regarding this type of conversion. SETTING Regional referral center and teaching hospital, Pennsylvania, United States; nonprofit. METHODS Between 2013 and 2016, a retrospective chart review was performed on all our revision cases. Patients who underwent conversion from RYGB to BPD-DS were selected and analyzed. RESULTS Conversion from RYGB to BPD-DS was performed on 9 patients (8 females, 1 male; mean age: 49.2±7.6 [36-61] years). The mean body mass index (BMI) before the initial RYGB was 54.2±14.2 (36.2-79) kg/m2. The lowest mean BMI reached before conversion was 33.9±6.2 (27.9-43.3) kg/m2 before it increased to 45.6±8.7 (28.8-60.2) corresponding to excess weight loss (EWL) of 33.1%±17.7% (10.6%-68.1%), before conversion. The average operative time was 402.6±65.8 (328-515) minutes for 1-stage conversions. No morbidities, reoperation, or readmission over 30 days postoperatively were reported. No leaks or mortalities were identified. The mean duration of follow-up postconversion is 16.3±13.6 (3-42) months. After conversion surgery, the mean BMI was 35.8±8.2 (27.6-49.5) kg/m2, while mean EWL loss was 64.1%±18.8% (45.9%-88.7%). The BMI of the cohort decreased by a mean of 9.8±5.1 (0.5-16.8) and the EWL increased by 31%±23.1% (4%-76.6%). CONCLUSION Our results indicate that conversion of failed RYGB to BPD-DS is laparoscopically or robotically safe and effective. A large cohort study with long-term follow-up is necessary to further assess the safety and efficacy of this method.

How to Switch to the Switch: Implementation of Biliopancreatic Diversion with Duodenal Switch into Practice

The biliopancreatic diversion with duodenal switch (BPD/DS), a modification of the classic Scopinaro procedure, carries the highest rate of success in terms of weight loss, comorbid resolution, and maintenance of weight loss. The substantial challenges, technical complexity, and expected roadblocks of adding BPD/DS option to the bariatric surgeon’s resources are reflected in the number of BPD/DS procedure performed in the USA, being less than 1% of all bariatric surgeries. Adjustments to the length of the common channel and the size of the vertical sleeve would increase the pool of candidates for BPD/DS and offer comprehensive management of obesity and metabolic comorbidities. Proper educational programs and multiple proctoring to bariatric surgeons aid to implement BPD/DS to their practice.

Venous thromboembolism after laparoscopic or robotic biliopancreatic diversion with duodenal switch. Ninety-days outcome of a 10 years’ experience

BACKGROUND Venous thromboembolism (VTE) is a feared complication after bariatric surgery. Biliopancreatic diversion with duodenal switch (BPD-DS) is a complex bariatric procedure that is offered typically to super morbidly obese patients. Scarce data exist in reporting VTE outcome and identifying the risk factors associated with it after BPD-DS. OBJECTIVE To determine the risk factors for VTE after BPD-DS at 90-day follow-up. SETTING A nonprofit regional referral center and teaching hospital in Pennsylvania. METHODS A retrospective chart review was performed on prospectively collected data over 10 years, between January 1, 2006 and December 31, 2016. Patients who underwent laparoscopic or robotic BPD-DS were included. Preoperative variables, selected risk factors, and methods of VTE prophylaxis were analyzed. RESULTS A total of 662 patients who underwent BPD-DS were identified. The mean age was 44.7 ± 10.4 (20-72) years; 474 patients were female (71.7%), and the mean body mass index of the cohort was 50.5 ± 7.5 (34-98) kg/m2. Overall, 16 patients (2.4%) experienced VTE complication at 90-days follow-up post-BPD-DS with 100% follow-up rate; deep vein thrombosis was experienced by 10 patients (1.5%), and 6 patients (0.9%) experienced pulmonary embolism (1 patient experience both). None of those patients had a previous history of VTE. Only operative time (P value = .009) and length of stay (P value ≤ .001) were associated with VTE events. Other factors such as age, sex, body mass index, previous history of VTE, preoperative heparin injection, preoperative inferior vena cava filter insertion, intermittent compressive device use, interval heparin time, and postoperative chemical prophylaxis did not show a statistical association. A logistic regression analysis showed a statistically significant increase of VTE outcome with length of stay; odds ratio of 1.161, (95% confidence interval, 1.048-1.285), P value = .004. CONCLUSION With proper preoperative evaluation and aggressive VTE prophylaxis protocol, the risk of VTE post-BPD-DS is comparable to other bariatric procedures. Every effort should be adopted to shorten the length of stay, and thus reduce VTE risk.

Repair of major lymphatic duct injury during laparoscopic sleeve gastrectomy

56 57 58 59 60 61 62 63 64 65 66 Injury to the thoracic duct or major tributaries with the resultant formation of chylous ascites or chylothorax is a rare complication of certain abdominal and thoracic operations. Very few cases have been reported after laparoscopic Roux-en-Y gastric bypass and laparoscopic Nissen fundoplication [1–3]. Herein, we report a video case of a major lymphatic duct injury during laparoscopic sleeve gastrectomy. This complication was recognized intraoperatively and the duct was successfully identified and ligated. 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 Case presentation

Laparoscopic cyst-gastrostomy after laparoscopic sleeve gastrectomy.

/10.10 15 P ence: , AU i_ala Pancreatic pseudocysts (PP) are confined collections of fluid from the pancreatic gland surrounded by nonepithelialized granulation tissue containing pancreatic juices. PP are not common, but they are usually a complication of pancreatitis. At this time, numerous classification systems are being used depending on the origin of the PP, its relation to the pancreatic duct, and the presence or absence of a pseudocyst–duct communication [1]. Diagnosis is often made with a computed tomographic (CT) scan, endoscopic retrograde cholangiopancreaticography (ERCP), or ultrasound. The vast improvement in diagnostic modalities has assisted in the detection of PP with a high sensitivity and specificity [2]. There are several therapeutic operative and nonoperative interventions for the treatment of symptomatic or large PP. These consist of endoscopic transpapillary or transmural drainage, percutaneous catheter drainage, or surgical drainage [3,4]. Herein, we report a laparoscopic cyst-gastrostomy in a patient who had previously undergone a laparoscopic sleeve gastrectomy and then developed a symptomatic PP.

Single-docking robotic biliopancreatic diversion with duodenal switch technique

Multiquadrant robotic surgery with single docking is a new feature that became available since the introduction of da Vinci XI® robotic platform. Laparoscopic Robotic assisted Biliopancreatic Diversion with Duodenal Switch (BPD/DS) was first described by Sudan et al in 2007. Robotic surgery advancement increased the interest in complex surgeries due to various advantages such as stable visualization, dexterity, ergonomic benefits and precise suturing. Described here is our technique of a total Robotic BPD/DS using single docking da Vinci XI® robotic platform, integrated table motion pairing, robotic stapling and robotic energy device.

Original articleVenous thromboembolism after laparoscopic or robotic biliopancreatic diversion with duodenal switch. Ninety-days outcome of a 10 years’ experience

BACKGROUND Venous thromboembolism (VTE) is a feared complication after bariatric surgery. Biliopancreatic diversion with duodenal switch (BPD-DS) is a complex bariatric procedure that is offered typically to super morbidly obese patients. Scarce data exist in reporting VTE outcome and identifying the risk factors associated with it after BPD-DS. OBJECTIVE To determine the risk factors for VTE after BPD-DS at 90-day follow-up. SETTING A nonprofit regional referral center and teaching hospital in Pennsylvania. METHODS A retrospective chart review was performed on prospectively collected data over 10 years, between January 1, 2006 and December 31, 2016. Patients who underwent laparoscopic or robotic BPD-DS were included. Preoperative variables, selected risk factors, and methods of VTE prophylaxis were analyzed. RESULTS A total of 662 patients who underwent BPD-DS were identified. The mean age was 44.7 ± 10.4 (20-72) years; 474 patients were female (71.7%), and the mean body mass index of the cohort was 50.5 ± 7.5 (34-98) kg/m2. Overall, 16 patients (2.4%) experienced VTE complication at 90-days follow-up post-BPD-DS with 100% follow-up rate; deep vein thrombosis was experienced by 10 patients (1.5%), and 6 patients (0.9%) experienced pulmonary embolism (1 patient experience both). None of those patients had a previous history of VTE. Only operative time (P value = .009) and length of stay (P value ≤ .001) were associated with VTE events. Other factors such as age, sex, body mass index, previous history of VTE, preoperative heparin injection, preoperative inferior vena cava filter insertion, intermittent compressive device use, interval heparin time, and postoperative chemical prophylaxis did not show a statistical association. A logistic regression analysis showed a statistically significant increase of VTE outcome with length of stay; odds ratio of 1.161, (95% confidence interval, 1.048-1.285), P value = .004. CONCLUSION With proper preoperative evaluation and aggressive VTE prophylaxis protocol, the risk of VTE post-BPD-DS is comparable to other bariatric procedures. Every effort should be adopted to shorten the length of stay, and thus reduce VTE risk.

Life threatening presentation of thoracic duct injury post thyroid surgery; a case report

Highlights • Injury to thoracic duct, and the formation of chyle leak, is a rare complication and carries significant metabolic and immunological consequences.• Thoracic duct injury during thyroid surgery is an uncommon event with an incidence rate of 0.5–1.8%.• High output chyle leak in a confined space was life threatening.• Surgeons must be familiar with thoracic duct anatomy.